Abnormal Fluid Collections Research Articles

Fetal hydropsia: challenges in etiologies

Introduction: Fetal hydrops is defined as the presence of abnormal fluid collections in two or more extravascular fetal compartments and body cavities. There are about 150 different underlying causes known today potentially leading to this fetal alteration. Objective: To analyze the etiologies involved in the occurrence of cases of fetal hydrops. Methods: A systematic literature review was carried out using the MedLine, Pubmed and Scielo databases, from 2015 to 2021, using the expressions: "fetal, hydrop, etiologies." Discussion: Fetal hydrops is divided into immune and non-immune. Immune results from anemia secondary to erythroblastosis by alloimmunization, so when there is maternal exposure to fetal antigens, it generates an immune response that results in the production of antibodies. History of blood transfusions, previous births, trauma and a history of alloimmunization are characterized as risk factors. Thus, immunoprophylaxis with anti-D immunoglobulin is indicated for all RhD negative pregnant women, with RhD positive male partner, with abundant fetal maternal hemorrhage during childbirth or events with potential sensitizer in the prenatal period. Conclusion: For an effective treatment, it is essential to identify the type of fetal hydrops in the patient and then the etiology of the disease, which is quite variable in Non-Immune Fetal Hydrops.

Clinical Profile and Predictors of Mortality in Neonates Born With Non-Immune Hydrops Fetalis: Experience From a Lower-Middle-Income Country.

IntroductionHydrops fetalis (HF) is a life-threatening condition in which a fetus has an abnormal collection of fluid in the tissue around the lungs, heart, abdomen, or under the skin. Based on its pathophysiology, it is classified into immune and non-immune types. With the widespread use of anti-D immunoglobulin, non-immune HF has become more common, with an incidence of one in 1,700-3,000 live births. A multitude of fetal diseases with various causes can lead to non-immune HF. Due to the recent advances in prenatal diagnostic and therapeutic interventions together with improved neonatal intensive care, the diagnosis and subsequent management of HF have been refined. However, HF is still associated with a high mortality rate. A recent assessment of the literature found that there is a lack of data on prognostic variables in neonates with HF from low- and middle-income countries. In light of this, we sought to establish the etiologic causes, predictors of mortality, and eventual fate of newborns born non-immune HF at the Aga Khan University Hospital, Karachi during the 10-year period spanning January 2009-December 2019 in this retrospective analysis.MethodologyFor this study, we collected data from the computerized database and patient record files at the hospital on all infants with non-immune HF. Demographic data, postnatal interventions, clinical and laboratory findings, outcomes, and the results of comparison between HF patients who died and those who survived were analyzed.ResultsThe incidence of non-immune HF at our hospital was 0.62/1,000 live births during the period under study, with 33 newborn babies diagnosed with non-immune HF from a total of 53,033 live-born deliveries. An etiologic factor was discovered in 17 (51.5%) neonates with non-immune HF while 16 (48.4%) were classified as those with unidentified etiology. The most common causes were cardiovascular and genetic syndromes, which resulted in 100% mortality. The overall mortality rate was 67%. The need for mechanical ventilation, surfactant therapy, and prolonged hospitalization were identified as independent risk factors of mortality.ConclusionOur study proves that the need for mechanical ventilation [moderate to severe hypoxic respiratory failure (HRF)] and prolonged hospitalization are strong predictors of poor outcomes in neonates with non-immune HF. Therefore, severe hydrops causing significant mortality can be anticipated based on the patients' respiratory status and the need for escalated oxygen support.

Imaging of Cardiac Device-Related Infection

Cardiac devices are frequently used in different cardiovascular conditions for the purpose of morbidity or mortality prevention. These include cardiac implantable electronic devices (CIED) like permanent pacemakers and implantable cardiac defibrillators, ventricular assistance devices (VADs), left atrial appendage occlusion (LAAO) devices like the Watchman™, atrial and ventricular septal occluders like the Amplatzer™, among others. In the past years, there has been an increase in the development of these devices as a result of a rise in the number of indications for implantation, paired with the aging and more medically complex patient population. This has led to an increase in the incidence of cardiac device-related infections, one of the most feared and serious complications which is associated with significant morbidity, mortality and financial burden. Accurate diagnosis of cardiac device-related infections is essential given the management implications which often involve removal of the infected device, removal of other prosthetic material and long-term antimicrobial therapy. Clinical and laboratory data are useful diagnostic tools but multimodality imaging is often necessary. The recently published 2020 European Heart Rhythm Association International Consensus document, which is endorsed by many expert societies, has recommended the use of multimodality imaging for the diagnosis of CIED infections. (1) This allows better disease characterization by identifying abnormal fluid collections and guiding aspiration for both diagnostic and therapeutic purposes (i.e. soft tissue ultrasound and computed tomography), evaluation for local extent of disease (i.e. transesophageal echocardiogram to evaluate for concomitant infective endocarditis), embolic manifestation of disease (i.e. computed tomography and magnetic resonance imaging) and metabolic tissue characterization (positron emission tomography and tagged white blood cell scan). (2) In addition, computed tomography (CT) allows for pre-procedural planning which has shown to be associated with better procedural outcomes.

Giant Communicating Hydrocele in a 36-Year-Old Nigerian Man

Hydrocele can be defined as an abnormal collection of fluid within the tunica vaginalis of the scrotum or along the spermatic cord. Giant hydroceles contain over 1 L of fluid and are rare. Communicating hydrocele, which occurs due to abnormal persistence of patency of the processus vaginalis (PV), is usually found in infants. This patency has been known to persist in some adults usually giving rise to an indirect inguinal hernia if symptomatic. Very rarely may also be a cause of hydrocele in adults. We managed a 36-year-old man who had a recurrent left scrotal swelling. High ligation of the left patent PV was done and 1.1 L of scrotal fluid collection drained. Giant hydrocele from communicating hydrocele is very rare. A communicating hydrocele should be considered as a differential diagnosis in an adult who develops a recurrence following open drainage of a hydrocele. Health education and improvements in standards of living will prevent communicating hydrocele from developing into giant hydrocele.

Retroperitoneal lymphatic malformation causing scrotal swelling– a useful diagnostic work-up with two-phase MRI to differentiate from scrotal lymphatic malformation or abdomino-scrotal hydrocele

Lymphatic malformation (LM) is an abnormal collection of lymphatic fluid within cysts or channels. LM can occur in any part of the body, but LM leading to scrotal swelling is very rare, and this unusual location often leads to diagnostic errors because the most common cause of a scrotal cystic lesion is a hydrocele. In the case presented here, a previously healthy 3-year-old boy recently developed a left scrotal swelling clinically mimicking a communicating hydrocele. However, a diagnostic laparoscopy showed a cystic lesion at the left internal inguinal ring with a closed internal inguinal ring, which is not an expected finding of communicating hydrocele. Differential diagnoses at surgery were scrotal LM, retroperitoneal LM, or abdomino-scrotal hydrocele (ASH). Two phase MRI performed both at the time of scrotal swelling and scrotal non-swelling showed a retroperitoneal LM bulging into the scrotum via the inguinal canal. Therefore, the retroperitoneal LM was completely resected using the inguinal approach. LM causing scrotal cystic lesion is rare, and it requires a high index of suspicion to make the correct diagnosis. Laparoscopy was needed to rule out the communicating hydrocele, and two-phase MRI was very useful to differentiate retroperitoneal LM causing scrotal swelling from scrotal LM or ASH. Both examinations helped with diagnosis and treatment planning.

Robotic Resection and Revision of Uterine Scar Defect with Hysteroscopic Guidance

Study Objective To demonstrate the steps of a robotic-assisted resection and revision of a uterine scar defect with hysteroscopic guidance and review tips and trips for this rare surgical procedure. Design This video describes the step by step approach to a robotic resection and revision of a uterine scar defect using hysteroscopic guidance to identify the target anatomy. Additionally, we describe tips and tricks to utilize while performing this rare surgical procedure to facilitate identification of the uterine scar laparoscopically, resect the defect in its entirety, improve hemostasis, and place a supportive suture for revision. Setting The patient was placed in dorsal lithotomy position in preparation for both hysteroscopic and robotic access. Patients or Participants In this surgical video, we present a case of a women with secondary infertility and a uterine scar defect in the setting of a history of prior cesarean delivery. She was referred by an REI physician due to history of aborted embryo transfers with abnormal fluid collections in the uterine defect. Interventions Robotic-assisted resection and revision of the uterine scar defect with hysteroscopic guidance. Measurements and Main Results Complete resection and reapproximation of the defect was visualized both laparoscopically and hysteroscopically without evidence of leakage of hysteroscopic fluid through the incision. Conclusion A minimally invasive approach to uterine scar defects can utilize simultaneous robotic-assisted laparoscopy and hysteroscopic guidance to identify the defect for resection and revision in symptomatic women or for fertility indications.

AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days.

AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days.

Evaluation of Different Modalities in Prevention of Seroma Formation Post Modified Radical Mastectomy

Background: Seroma is an abnormal collection of serous fluid in the dead space of post-mastectomy skin flaps and axilla or following breast-conserving surgery. Seroma is one of the most common early post-operative complications following surgery for breast cancer. Various studies report an incidence ranging from 10% to 85% following modified radical mastectomy (MRM) or axillary lymph node dissection (ALND). Objective: Evaluation of different modalities in the prevention of seroma formation post modified radical mastectomy. Patients and methods: This was a prospective comparative study carried out in the General Surgery Department, Faculty of Medicine, Aswan University, Aswan, Egypt. in the period between December 2017 and June 2018. Patients scheduled for modified radical mastectomy during the period of study were randomly divided into three groups, mastectomy flap fixation group (10 cases), ipsilateral shoulder immobilization group (10 cases) & (pre & post) operative tranexamic acid usage group (10 cases). Results: Hypertension, obesity, blood transfusion, and bloody field are at high risk of developing seroma after MRM; while DM, cancer stage, number of LN infiltrated and removed don’t affect on seroma formation after MRM. Flap fixation was found to be the best modality in the prevention of seroma formation with a low incidence in developed seroma and other complications. On the other hand, tranexamic acid usage pre- and post-operative found that no role in the prevention of seroma formation after MRM. Conclusion: The mastectomy flap fixation technique is a valuable procedure that significantly decreases the incidence of seroma formation, and reduces the duration and amount of drained fluid.

SUN-LB89 Resolution of Hashimoto Thyroiditis: A Case of Hashimoto Thyroiditis Evolving Into Subacute Thyroiditis and Euthyroidism

Background: Subacute thyroiditis (SAT) is a transient inflammatory disorder of the thyroid gland, whereas Hashimoto thyroiditis (HT) is an autoimmune disorder. These two disease entities have quite different pathogenic mechanisms and typically do not co-occur. The objective of this report is to describe a patient with HT with eventual evolution into SAT to euthyroid. We review the diagnostic challenges of an uncommon presentation of Hashimoto thyroiditis with SAT.Clinical Case:52-year old female diagnosed with Hashimoto thyroiditis with subsequent development of hypothyroidism 10 years ago presented to our endocrinology clinic for the management of hyperthyroidism. She was diagnosed previously 10 years ago with reported elevated TSH, low FT4 and positive antibody testing assumed to include elevated anti-thyroid peroxidase. Therefore, at the time of her diagnosis she was started on levothyroxine 25 mcg daily and increased over time to 75 mcg daily. Approximately several months prior to her clinic visit with us, she began having a sore throat with subsequent development of voice hoarseness and tachycardia associated with palpitations lasting persistently for 1 month. She endorsed symptoms 2 months prior with having pain in her lower anterior neck described as non-radiating, intermittent and sharp associated with voice hoarseness, palpitations, racing heart and jitteriness that was exacerbated while palpating area. Her symptoms have since improved to having mild voice hoarseness. Her past medical history aside from hypothyroidism is Celiac disease and migraines. Her medications included Erenumab 70 mg once monthly and sumatriptan 100 mg as needed. During her evaluation, her blood pressure was 120/75, heart rate 72 bmp, temperature 36.0 C. Her physical exam was remarkable for mild tenderness of the anterior inferior midline neck without obvious masses or lesions. Ultrasound of her neck revealed heterogenous echotexture of the entire thyroid gland is noted with diffuse increased vascularity. The right thyroid lobe measured 4.2 x 1.0 x 1.5 cm and left thyroid lobe measures 4.0 x 1.0 x 1.3 cm without focal lesion is noted within either lobe. The soft tissues of the neck are unremarkable. There are no abnormal masses or fluid collections. Visualized lymph nodes are unremarkable in size and did not demonstrate increased vascularity. These findings were consistent with thyroiditis. Laboratory values obtained during her initial symptoms revealed slight hyperthyroidism with a TSH 0.05 mU/L (normal range, 0.8 to 1.7 mU/L) and FT4 2.0 ng/dL (normal range, 0.45 - 4.50 ng/dL), therefore her treatment with levothyroxine was discontinued. She was not started on any additional treatment as her symptoms were self-resolving. Repeat laboratory values in 4 weeks showed completely normal thyroid laboratory value with TSH 4.36 mU/L (normal range, 0.8 to 1.7 mU/L) and FT4 1.1 ng/dL (normal range, 0.45 - 4.50 ng/dL).Conclusion: HT is thought to be autoimmune in origin with lymphocytic infiltration and fibrosis. Early in the disease course, hyperthyroidism may result from destruction of the thyroid gland cells. HT is known to be a life-long disorder with essentially a non-functional thyroid. It is well established that SAT may evolve to HT and that HT may transform in Grave’s disease. Additionally, painful HT mimicking SAT has also been reported. There have been few reported cases of HT progressing into hyperthyroidism secondary to SAT and further resolution to euthyroid function.

The role of laparoscopy in the diagnosis of ascites of unknown etiology

Objective We aimed to analyze the effect of diagnostic laparoscopy in the identification of the cause of ascites that had been failed to be known by all other diagnostic procedures. Patients and methods This study included 20 patients with an ascites of unknown cause. Before diagnostic laparoscopy, all patients underwent clinical, laboratory, and radiological evaluations; however, all these tools failed to identify the actual cause of this abnormal free fluid collection in the abdominal cavity. Data collection and statistically analysis were done. Results The cause of ascites was identified in 18/20 of our patients, with an accuracy of 90%. Overall, 40% of ascites in our study were owing to tuberculosis, whereas malignancy was the cause of ascites in 20% of patients, and liver cirrhosis and peritonitis were the cause in 15% of each. Conclusion Laparoscopy can help in the safe and effective diagnosis of cases of ascites of unknown etiology.

Insights into the pathogenesis of cystoid macular edema: leukostasis and related cytokines.

Cystoid macular edema (CME) is the abnormal collection of intraretinal fluid in the macular region, especially in the inner nuclear and outer plexiform layers. CME leads to severe visual impairment in patients with various retinal diseases, such as diabetic retinopathy, retinal vascular occlusion, choroidal neovascularization, and uveitis. Although various retinal conditions lead to CME, a shared pathogenesis of CME is involved in these diseases. Accordingly, the pathogenesis of CME based on vasogenic mechanisms is first discussed in this review, including vascular hyperpermeability, leukostasis, and inflammation. We then describe cytotoxic mechanisms based on retinal Müller cell dysfunction. This comprehensive review will provide an understanding of the pathogenesis of CME for potential therapeutic strategies.

Advanced hemostasis in axillary lymph node dissection for locally advanced breast cancer: new technology devices compared in the prevention of seroma formation

BackgroundBreast cancer is the most frequent neoplasm in women. Axillary lymph nodes dissection represents the treatment of choice in locally advanced breast cancer for prognostic and curative purposes. Seroma formation, an abnormal collection of fluid in the dead space of the axilla, is described in Literature with a wide range of incidence (3–85%). It is a source of significant morbidity and discomfort. The aim of the study is to compare the different haemostasis devices used in breast surgery, investigating the eventual superiority of an instrument among the others in terms of intraoperative and postoperative outcome, especially of seroma formation.MethodsClinical cases of female patients undergone axillary lymph nodes dissection for local advanced breast cancer between January 2013 and July 2017 at the Surgery Unit of University of Campania “Luigi Vanvitelli” were retrospectively reviewed. Patients were divided into four groups, according to device utilized during surgery: Electrocautery, Harmonic Scalpel, LigaSure and Thunderbeat. All patients underwent II level axillary lymph nodes dissection associated to radical mastectomy or quadrantectomy.ResultsOne hundred consecutives patients were enrolled in the study. Intra-operative blood loss resulted statistically significant different (P < 0,01) between the Electrocautery group (94,7 ml) and the Thunderbeat group (57,2 ml), while the Harmonic Scalpel group and the Ligasure group, despite presented a lower amount of blood loss, did not differ significantly. Drainage volume resulted significantly lower (P = 0,002) in the comparison between the Electrocautery group and the Thunderbeat group; the Ligasure group and Harmonic Scapel group showed no difference between them and Electrocautery group. About the seroma formation, the Electrocautery group resulted affected by the highest seroma formation rate (64%). Seroma incidence in Harmonic Scalpel group was 24%, in Ligasure group was 44%, while Thunderbeat group showed the lowest presentation of seroma with 16%.ConclusionsIn patients affected by breast cancer requiring axillary lymphnodes dissection, the use of advanced hemostasis devices is highly desirable. Among the non-traditional tools, Thunderbeat resulted to be superior in terms of reduction of intra-operative blood loss and post-operative drainage output, moreover associated to a substantial reduction of postoperative seroma incidence.

NIHILISTIC DELUSION IN THE CONTEXT OF MAJOR DEPRESSIVE DISORDER WITH CATATONIC FEATURES IN A GERIATRIC PATIENT: A CASE REPORT AND REVIEW OF LITERATURE

NIHILISTIC DELUSION IN THE CONTEXT OF MAJOR DEPRESSIVE DISORDER WITH CATATONIC FEATURES IN A GERIATRIC PATIENT: A CASE REPORT AND REVIEW OF LITERATURE

ERCP-associated infected intrahepatic pancreatic pseudocyst.

IntroductionPancreatic pseudocysts are abnormal mature collections of pancreatic fluid that can develop in association with acute or chronic pancreatitis. Here, we share the discovery of an infected hepatic subcapsular pseudocyst of the pancreas causing septic shock following endoscopic retrograde cholangiopancreatography (ERCP).Presentation of CaseA 55-year-old woman with ethanol-related chronic pancreatitis and biliary stricture was transferred to the ICU for hypotension 8 hours following ERCP. Examination revealed mild right upper quadrant tenderness without sign of peritonitis. Laboratory studies were notable for leukocytosis (14.6 k/L) and slightly elevated serum lipase (489 U/L). Abdominal CT scan revealed a previously undescribed subcapsular fluid collection. She underwent CT-guided percutaneous subcapsular drainage with return of opaque yellowish fluid. Fluid analysis showed elevated lipase of 62,901 U/L with cultures positive for ESBL Escherichia coli, Streptococcus constellatus, and Enterococcus faecium.DiscussionA majority of pancreatic pseudocysts develop in peripancreatic regions, while, in a recent study, over a quarter of cases were found in usual sites. The management of subcapsular pseudocysts has not been standardized and often involves endoscopic or percutaneous drainage. Operative intervention is reserved for severe infection or rupture in patients with intrahepatic pseudocysts. Rarely do subcapsular pseudocysts become infected. In this case, we postulate the pseudocyst became seeded by bacteria during ERCP resulting in infection and then sepsis.ConclusionThis case report highlights an atypical presentation of pancreatic pseudocyst as well as a rare septic complication of ERCP.

Delayed Post Caudal Catheter Placement Pseudomeningocele: A Case Report.

We present a rare case of a 7-month-old infant who developed a pseudomeningocele 16 days after an uneventful caudal catheter placement. The patient did not exhibit neurological deficits or signs of infection, and the mass increased in size with Valsalva maneuver. Pseudomeningocele, an abnormal collection of cerebrospinal fluid around an opening in the dura mater, can be iatrogenic or traumatic. Regional anesthesia is rarely the cause. Recognizing diagnostic features such as the lack of infectious signs and mass compressibility can prevent misdiagnosis and inappropriate invasive treatment.

Epidural Fluid Collection After Percutaneous Endoscopic Lumbar Discectomy.

The frequency and extent of epidural fluid collection after percutaneous endoscopic lumbar discectomy (PELD) have not been previously described. The purpose of this study was to evaluate the significance of epidural fluid collection after PELD. From March 2008 to November 2015, immediate postoperative magnetic resonance imaging (MRI) of 464 consecutive patients, comprising 284 men and 180 women, were obtained after PELD. The mean age of the patients at the time of admission was 43.1 years (range, 18-81 years). We also performed 24-hour follow-up MRIs after PELD in 35 patients to evaluate the morphologic changes on epidural fluid collection and to identify whether the collection was due to saline accumulation or cerebrospinal fluid leak. The level of disc herniation was at L4-5, L5-S1, L3-4, and L2-3 in 245 (52.8%), 173 (37.3%), 37 (8.0%), and 9 (1.9%) patients, respectively. Of 464 patients, 418 (90.1%) had abnormal epidural fluid collection, 404(87.1%) patients had ventral epidural fluid collection, 393 (84.7%) patients had dorsal epidural fluid collection, and 10 patients had epidural hematoma as per immediate postoperative MRI. According to the 24-hour follow-up MRI findings, 30 patients had epidural fluid collection; the epidural fluid collection in 28 patients (93.3%) resolved with time, and a minimal amount of fluid remained in 2 patients, but the lesion size decreased compared with that on the previous day. Epidural fluid collection usually occurs after percutaneous endoscopic discectomy, which is mainly due to saline accumulation and typically resolves with time, without treatment or complications.

Etiology and clinical profile of pleural effusion

Background: Pleural effusion is an excessive or abnormal collection of fluid in pleural space. Etiological study of pleural effusions is challenging to the physician as it differs depending on the region where the study is being carried out and the population involved. Objective: In this study, we aimed to identify the common etiologies causing pleural effusion and their clinical profile in a teaching institution. Materials and Methods: It was a prospective evaluation of 250 consecutive cases of pleural effusion. Detailed history and physical examination, pleurocentesis and pleural fluid analysis were done in all cases and closed pleural biopsy, computed tomography (CT), fiber-optic bronchoscopy, and other relevant examination in selected cases. Results: The most common cause pleural effusion in this study was tuberculosis (68.8%), followed by malignancy (14%), empyema (6%), and transudative effusion (2.8%). Pleural effusion was commonly seen in male (66%). The occurrence of tubercular pleural effusion was maximum in the age group 21–30 years, but malignant pleural effusion was more common above 60 years of age. Right-sided effusions were more common. Estimation of pleural fluid adenosine deaminase plays a significant role in the diagnosis of tubercular pleural effusion. Pleural fluid cytology and closed pleural biopsy can diagnose most of the cases of pleural effusion due to malignancy. Conclusion: The etiological diagnosis of pleural effusion remains unchanged even after few decades in our country. Even after thorough investigations with the help of closed pleural biopsy, fiber optic bronchoscopy, CT scan and CT guided fine needle aspiration cytology and others, 5.2% of cases could not be diagnosed. It has been also observed in another study where 15% cases remain undiagnosed. Thoracoscopic pleural biopsy may narrow down this gap.

The long-term outcomes of cirrhotic patients with pleural effusion.

Background/Aim:A pleural effusion is an abnormal collection of fluid in the pleural space and may cause related morbidity or mortality in cirrhotic patients. Currently, there are insufficient data to support the long-term prognosis for cirrhotic patients with pleural effusion. In this study, we investigated the short- and long-term effects of pleural effusion on mortality in cirrhotic patients and evaluated the benefit of liver transplantation in these patients.Patients and Methods:The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify 3,487 cirrhotic patients with pleural effusion requiring drainage between January 1, 2007 and December 31, 2010. The proportional hazards Cox regression model was used to control for possible confounding factors.Results:The 30-day, 90-day, 1-year, and 3-year mortalities were 20.1%, 40.2%, 59.1%, and 75.9%, respectively, in the cirrhotic patients with pleural effusion. After Cox proportional hazard regression analysis adjusted by patient gender, age, complications of cirrhosis and comorbid disorders, old age, esophageal variceal bleeding, hepatocellular carcinoma, hepatic encephalopathy, pneumonia, renal function impairment, and without liver transplantation conferred higher risks for 3-year mortality in the cirrhotic patients with pleura effusion. Liver transplantation is the most important factor to determine the 3-year mortalities (HR: 0.17, 95% CI 0.11- 0.26, P < 0.001). The 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortalities were 5.7%, 13.4%, 20.4%, and 21.7% respectively, in the liver transplantation group, and 20.5%, 41.0%, 61.2%, and 77.5%, respectively, in the non-liver transplantation group.Conclusion:In cirrhotic patients, the presence of pleural effusion predicts poor long-term outcomes. Liver transplantation could dramatically improve the survival and should be suggested as soon as possible.

Non-Immune Hydrops Fetalis: Do Placentomegaly and Polyhydramnios Matter?

Polyhydramnios and placentomegaly are commonly observed in nonimmune hydrops fetalis (NIHF); however, whether their ultrasonographic identification is relevant for prognosis is controversial. We evaluated outcomes of fetal or neonatal death and preterm birth (PTB) in cases of NIHF alone and in those with polyhydramnios and/or placentomegaly (P/PM). We conducted a retrospective cohort of singletons with NIHF evaluated between 1994 and 2013. Nonimmune hydrops fetalis was defined as 2 or more abnormal fluid collections, including ascites, pericardial effusion, pleural effusion, and skin edema. Primary outcomes were intrauterine fetal demise (IUFD) and neonatal death. Secondary outcomes were PTB (<37, < 34, and <28 weeks) and spontaneous PTB. Outcomes were compared between cases of NIHF alone and NIHF with P/PM. A total of 153 cases were included; 21% (32 of 153) had NIHF alone, and 79% (121 of 153) had NIHF with P/PM. There was no significant difference in neonatal death (38.1% versus 43.0%; P = .809) between the groups. Intrauterine fetal demise was seen more frequently in NIHF alone (34.4% versus 17.4%; P = .049). Nonimmune hydrops fetalis-with-P/PM cases were more likely to deliver before 37 weeks (80.0% versus 57.1%; P = .045) and before 34 weeks (60.0% versus 28.6%; P = .015) and to have spontaneous PTB (64.4% versus 33.3%; P = .042). Adjusted odds ratios accounting for the etiology of NIHF supported these findings, with the exception of IUFD. Compared to NIHF alone, pregnancies with NIHF and P/PM had a lower risk of IUFD and were at increased risk of PTB (<37 and <34 weeks) and spontaneous PTB. This information may help providers in counseling patients with NIHF and supports the need for close antenatal surveillance.

A Rare Case of Ruptured Mediastinal Pancreatic Pseudocyst

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Development of pseudocysts is common in patients with chronic pancreatitis. Usually pseudocysts are located within the abdomen or the pancreatic body. Mediastinal pancreatic pseudocysts represent a rare complication associated with chronic pancreatitis.1 Depending on location patients may present with dyspnea or dysphagia2. CASE PRESENTATION: A 42 year old female presented with one month history of progressively worsening dyspnea and pleuritic chest pain. She endorsed mild abdominal pain without nausea, vomiting or diarrhea. Past medical history was relevant for recent pleural effusion two months prior, chronic pancreatitis and alcohol dependence. She was slightly tachypneic and hypoxic. On exam she had dullness to percussion of the left chest wall. Abdominal exam showed present bowel sounds with mild epigastric tenderness, without abdominal distension. Chest xray suggested whiteout of the left lung field with contralateral shifting of the mediastinum. CT scan of the chest showed a large left sided pleural effusion with contralateral mediastinal shift and passive collapse of the lung, abnormal paraesophageal fluid collection continuing through the esophageal hiatus into the gastrohepatic ligament was seen. Thoracentesis was performed which showed an exudative effusion, with an amylase level of 10377. Microbiologic and Histopathologic analysis failed to show evidence of infection or malignancy. MRCP did not show any pancreatic ductal obstruction or pancreatic fistula to the mediastinal collection. It was determined that the cause of her pleural effusion was rupture of the mediastinal collection representing a pancreatic pseudocyst. She underwent surgical lysis of adhesions and decortication of pleura. At 3 month follow up post discharge patient failed to show evidence of reaccumulation of mediastinal or ascitic fluid. DISCUSSION: Conservative management with somatostatin analogues is the mainstay therapy for pancreaticopleural fistula prior to surgical intervention. In our patient we opted for surgical resection as there was no active communication between the pancreas and the pseudocyst. CONCLUSIONS: We present a rare case of a mediastinal pancreatic pseudocyst that manifested as a recurrent large pleural effusion requiring surgical intervention. Reference #1: Drescher R, et. al. Mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report. Journal of Medical Case Reports. 2008;2:180. Reference #2: Chettupuzha AP, et. al. Pancreatic pseudocyst presenting as odynophagia. Indian J Gastroenterol. 2004;23:27-28. DISCLOSURE: The following authors have nothing to disclose: Syed Iqbal, Catherine Stadler, Javed Iqbal No Product/Research Disclosure Information